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To be completed by the Applicant: Please type or print using blue or black ink, using your full legal name:Last Name: First Name M.I.: Preferred Name: Gender: Male Female Address:City: State: Zip
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Please type the requested information or print clearly to ensure legibility.
The individuals or entities specified in the form instructions are required to file.
Follow the instructions provided in the form and make sure to accurately complete all required fields.
The purpose is to collect necessary information for reporting and compliance purposes.
All relevant information as outlined in the form instructions must be reported.
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